Fillable Printable Vba 21 0960M 10 Are
Fillable Printable Vba 21 0960M 10 Are
Vba 21 0960M 10 Are
SECTION I - DIAGNOSIS
VA FORM
DEC 2014
21-0960M-10
MUSCLE INJURIES DISABILITY BENEFITS QUESTIONNAIRE
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO MUSCLE INJURIES:
OMB Approved No. 2900-0776
Respondent Burden: 30 Minutes
Expiration Date: 11/30/2017
NOTE - If there are multiple muscle injuries, complete the assessment for all muscle injuries on this questionnaire, if possible. If unable to complete assessment for all muscle injuries on this
questionnaire, also complete an additional questionnaire for each additional injury. If the veteran has or has had a muscle injury that results in any conditions that are not covered in this
questionnaire, also complete any other appropriate questionnaires (e.g., if peripheral nerve injury also exists due to the muscle injury, complete VA Form 21-0960C-10, Peripheral Nerve
Conditions (not including diabetic sensory-motor peripheral neuropathy) Disability Benefits Questionnaire.
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAYOR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
BEFORE COMPLETING FORM.
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO MUSCLE INJURIES, LIST USING ABOVE FORMAT:
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A MUSCLE INJURY?
(If "Yes," complete Item 1B)
Right
Left
2D. DOMINANT HAND
3. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?
Both
AMBIDEXTROUSRIGHTLEFT
DIAGNOSIS #1 -
ICD CODE - DIAGNOSIS #3 -
DATE OF DIAGNOSIS -
ICD CODE -
DATE OF DIAGNOSIS -
2A. DOES THE VETERAN HAVE A PENETRATING MUSCLE INJURY
(such as a gunshot or shell fragment wound)?
SIDE AFFECTED
DIAGNOSIS #2 - ICD CODE -
DATE OF DIAGNOSIS -
Right
Left
Both
SIDE AFFECTED
NO
Right
Left
Both
SIDE AFFECTED
YES
SECTION II - HISTORY OF MUSCLE INJURY
NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQ's completed by
private health care providers.
NOYES
NOYES
SECTION III - LOCATION OF MUSCLE INJURY
2C. DESCRIBE THE HISTORY (including onset and course)OF THE VETERAN'S MUSCLE INJURY(brief summary)
Page 1
NOYES
SHOULDER GIRDLE AND ARM
NOTE - For VA purposes, muscles are classified into groups I-XXIII. In this section, indicate the location of the veteran's muscle injury(ies) by checking the
muscle group(s) involved.
2B. DOES THE VETERAN HAVE A NON-PENETRATING MUSCLE INJURY (such as a muscle strain, torn Achilles tendon or torn quadriceps muscle)?
Both
Side affected:
GROUP VI: Extensor muscles of elbow: triceps
Function: Extension of elbow
Left
Right
Both
Side affected:
(If "Yes," check muscle group(s) and side affected (check all that apply)
Both
Side affected:
GROUP I: Extrinsic muscles of shoulder girdle: trapezius, levator scapulae, serratus magnus
Function: Upward rotation of scapula, elevation of arm above shoulder level
Left
Right
GROUP II: Muscles of shoulder girdle: pectoralis major, latissimus dorsi and teres major, pectoralis minor, rhomboid
Function: Depression of arm from vertical overhead to hanging at side, downward rotation of scapula, forward and
backward swing of arm
Left
Right
Both
Side affected:
GROUP III: Intrinsic muscles of shoulder girdle: pectoralis major, deltoid
Function: Elevation and abduction of arm to level of shoulder, forward and backward swing of arm
Left
Right
Both
Side affected:
GROUP IV: Shoulder girdle muscles: supraspinatus, infraspinatus and teres minor, subscapularis, coracobrachialis
Function: Stabilization of shoulder, abduction, rotation of arm
Left
Right
Both
Side affected:
GROUP V: Flexor muscles of elbow: biceps, brachialis, brachioradialis
Function: Flexion of elbow
Left
Right
SUPERSEDES VA FORM 21-0960M-10, OCT 2012,
WHICH WILL NOT BE USED.
Page 2
(If "Yes," check muscle group(s) and side or region affected (check all that apply)
PELVIC GIRDLE AND THIGH
NOYES
6. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?
FOOT AND LEG
BothSide affected:
GROUP XXIII: Muscles of the side and back of the neck: suboccipital, lateral vertebral and anterior vertebral muscles
Function: Movements of the head, fixation of shoulder movements
Left
Both
Both
Side affected:
GROUP XIX: Muscles of the abdominal wall: rectus abdominis, external oblique, internal obliques, transversalis, quadratus lumborum
Function: Support of abdominal wall and lower thorax, flexion and lateral movement of spine
Left
Both
Side affected:
Both
Side affected:
GROUP X: Muscles of the foot: flexor digitorum brevis, abductor hallucis, abductor digiti minimi, quadratus plantae, lumbricales,
flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis, dorsal and plantar interossei
Function: Movements of forefoot and toes, propulsion thrust in walking
Left
Right
GROUP XI: Muscles of the foot, ankle and calf: gastrocnemius, soleus, tibialis posterior, peroneus longus, peroneus brevis,
flexor hallucis longus, flexor digitorum longus
Function: Propulsion, plantar flexion of foot, stabilization of arch, flexion of toes
Left
Right
BothSide affected:
GROUP XII: Anterior muscles of the leg, tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius
Function: Dorsiflexion, extension of toes, stabilization of arch
LeftRight
Right
Side affected:
GROUP XXI: Muscles of respiration: thoracic muscle group
Function: Respiration
LeftRight
7. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP IN THE TORSO AND/OR NECK?
NOYES
SECTION III - LOCATION OF MUSCLE INJURY(Continued)
TORSO AND NECK
FOREARM AND HAND
Lumbar
Region affected:
If checked, is there severe damage to muscle group XVII, such that the veteran is unable to rise from a seated and stooped position and to
maintain postural stability without assistance of any type?
Both
GROUP XX: Spinal muscles: sacrospinalis, erector spinae
Function: Postural support of body, extension and lateral movement of the spine
Thoracic
Cervical
Both
Side affected:
GROUP XVIII: Pelvic girdle muscles: pyriformis, gemelli, obturator, quadratus femoris
Function: Outward rotation of thigh and stabilization of hip joint
Left
Right
4. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?
(If "Yes," check muscle group(s) and side affected (check all that apply)
NO
YES
Both
Side affected:
Both
Side affected:
GROUP VII: Muscles of forearm: flexors of the wrist, fingers and thumb
Function: Flexion of wrist and fingers
LeftRight
GROUP VIII: Muscles: extensors of the wrist, fingers and thumb
Function: Extension of wrist, fingers and thumb
LeftRight
Both
Side affected:
GROUP IX: Intrinsic muscles of hand, including muscles in the thenar and hypothenar eminence, lumbricales, dorsal
and palmar interossei
Function: Intrinsic muscles of the hand assist in delicate manipulative movements
Left
Right
Right
(If "Yes," check muscle group(s) and side affected (check all that apply)
NOYES
Side affected:
GROUP XXII: Muscles of the front of the neck: trapezius, sternocleidomastoid, hyoid muscles, sternothyroid, digastric
Function: Rotation and flexion of the head, respiration, swallowing
LeftRight
Both
Side affected:
GROUP XVII: Pelvic girdle muscles: gluteus maximus, gluteus medius, gluteus minimus
Function: Extension of hip, abduction of thigh, postural support of body
Left
5. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?
(If "Yes," check muscle group(s) and side affected (check all that apply)
Both
Side affected:
NOYES
GROUP XIV: Anterior thigh muscles: sartorius, rectus femoris, quadriceps
Function: Extension of knee
Left
Right
Both
Side affected:
GROUP XV: Medial thigh muscles: adductor longus, adductor brevis, adductor magnus, gracilis
Function: Adduction of hip
Left
Right
Both
Side affected:
Both
Side affected:
GROUP XIII: Posterior thigh/hamstring muscles: biceps femoris, semimembranosus, semitendinosus
Function: Flexion of knee
Left
Right
GROUP XVI: Pelvic girdle muscles: psoas, iliacus, pectineus
Function: Flexion of hip
Left
Right
Right
VA FORM 21-0960M-10, DEC 2014
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
SECTION IV - ADDITIONAL CONDITIONS
Page 3
9A. DOES THE VETERAN HAVE ANY SCAR(S) ASSOCIATED WITH A MUSCLE INJURY?
(If "Yes," is there interference to any extent with mastication?)
Other, describe:
8A. DOES THE VETERAN HAVE A HISTORY OF RUPTURE OF THE DIAPHRAGM WITH HERNIATION?
(If "Yes," indicate severity of scar(s) caused by the muscle injury (ies) (check all that apply if there is more
than one area or type of scarring):
(If "Yes," ALSO complete VA Form 21-0960H-1, Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire)
(If "Yes," complete VA Form 21-0960C-3, Cranial Nerve Conditions Disability Benefits Questionnaire or VA Form 21-0960F-1, Scars/Disfigurement Disability
Benefits Questionnaire, etc., as indicated by type of residuals)
YES
NO
YES
Other (including surgical scars related to muscle injuries shown above, ALSO complete VA Form 21-0960F-1, Scars/Disfigurement
Disability Benefits Questionnaire):
Other, describe:
8B. DOES THE VETERAN HAVE A HISTORY OF AN EXTENSIVE MUSCLE HERNIA OF ANY MUSCLE, WITHOUT OTHER INJURY TO THE MUSCLE?
NO
YES
YES
Some impairment of muscle tonus
NO
Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle
SECTION V - MUSCLE INJURY EXAM
Adaptive contraction of an opposing group of muscles
9C. DOES THE VETERAN'S MUSCLE INJURY(IES) AFFECT MUSCLE SUBSTANCE OR FUNCTION?
Visible or measurable atrophy
Entrance and (if present) exit scars indicating track of missile through one or more muscle groups
Minimal scar(s)
Entrance and (if present) exit scars are small or linear, indicating short track of missile through muscle tissue
Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track
Tests of endurance or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function
Some loss of muscle substance
YES
NO
9B. DOES THE VETERAN HAVE ANY KNOWN FASCIAL DEFECTS OR EVIDENCE OF FASCIAL DEFECTS ASSOCIATED WITH ANY MUSCLE INJURIES?
(If "Yes," indicate severity of fascial defect(s) caused by the muscle injury(ies) (check all that apply if there is more than one area/type of fascial defect)
YES
NO
Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone
rather than true skin covering in an area where bone is normally protected by muscle
Induration or atrophy of an entire muscle following history of simple piercing by a projectile
Soft flabby muscles in wound area
Muscles swell and harden abnormally in contraction
(If "Yes," indicate effect of the muscle injury(ies) on muscle substance or function - check all that apply)
NO
SCAR(S), FASCIA AND MUSCLE FINDINGS
8C. DOES THE VETERAN HAVE A HISTORY OF INJURY TO THE FACIAL MUSCLES?
Some loss of deep fascia
Palpation shows loss of deep fascia
YES
NO
(If "Yes," provide name of muscle and describe current residuals):
VA FORM 21-0960M-10, DEC 2014
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
Page 4
10. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS AND/OR SYMPTOMS ATTRIBUTABLE TO ANY MUSCLE INJURIES?
(If "Yes," check all that apply, and indicate side affected, muscle group and frequency/severity):
SECTION V - MUSCLE INJURY EXAM (Continued)
YES
NO
(Indicate frequency/severity):
(Indicate frequency/severity):
Consistent at a more severe levelOccasionalConsistent
Fatigue-pain
(If checked, indicate side affected):
(Indicate muscle group(s) affected (I-XXIII) if possible):
BothRight
(Indicate frequency/severity):
Consistent at a more severe levelOccasionalConsistent
Weakness
(If checked, indicate side affected):
(Indicate muscle group(s) affected (I-XXIII) if possible):
Both
(Indicate frequency/severity):
Consistent at a more severe levelOccasionalConsistent
Loss of power
(If checked, indicate side affected):
(Indicate muscle group(s) affected (I-XXIII) if possible):
Both
Right
Left
RightLeft
(Indicate frequency/severity):
Consistent at a more severe levelOccasionalConsistent
Lowered threshold of fatigue
(If checked, indicate sided affected):
(Indicate muscle group(s) affected (I-XXIII) if possible):
BothRightLeft
Left
Consistent at a more severe levelOccasionalConsistent
Impairment of coordination
(If checked, indicate side affected):
(Indicate muscle group(s) affected (I-XXIII) if possible):
BothRightLeft
(Indicate frequency/severity):
Consistent at a more severe levelOccasionalConsistent
Uncertainty of movement
(If checked, indicate side affected):
(Indicate muscle group(s) affected (I-XXIII) if possible):
BothRightLeft
If further clarification is needed due to injuries of multiple muscle groups, describe which findings, signs and/or symptoms are attributable to each muscle injury:
CARDINAL SIGNS AND SYMPTOMS OF MUSCLE DISABILITY
VA FORM 21-0960M-10, DEC 2014
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
SECTION V - MUSCLE INJURY EXAM (Continued)
MUSCLE STRENGTH TESTING
Page 5
12. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YESNO
(If the veteran uses any assistive devices specify the condition and identify the assistive device used for each condition):
SECTION VI - ASSISTIVE DEVICES
11B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES
NO
(If "Yes," identify assistive devices used (check all that apply and indicate frequency):
Ankle dorsiflexion (Group XII)
If other movements/muscle groups
were tested, specify:
0/5
5/5
4/5
0/5
4/5
0/5
0/5
4/5
4/5
0/5
5/5
4/50/5
5/5
4/5
11A. TEST MUSCLE STRENGTH ONLY FOR AFFECTED MUSCLE GROUPS AND FOR THE CORRESPONDING SOUND (NON-INJURED) SIDE.
RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
5/5 Normal strength
2/5 No movement against gravity
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
3/5 No movement against resistance
4/5 Less than normal strength
Ankle plantar flexion (Group XI)
0/5
5/5
4/5
4/5
0/5
5/5
5/5
Left:
Right:
Shoulder abduction (Group III)
5/5
Left:
Right:
Elbow flexion (Group V)
Left:
Right:
5/5
Wrist extension (Group VIII)
0/5
5/5
4/5
4/5
0/5
3/5
3/5
3/5
3/5
3/5
3/5
2/5
2/5
2/5
2/5
2/5
2/5
5/5
Left:
Right:
3/5
3/5
2/5
2/5
1/5
1/5
Hip flexion (Group XVI)
0/5
5/5
4/5
4/5
0/5
5/5
Left:
Right:
3/5
1/5
1/5
1/5
1/5
1/5
1/5
3/5
2/5
2/5
1/5
1/5
Knee flexion (Group XIII)
Elbow extension (Group VI)
0/5
5/5
4/5
4/5
0/5
5/5
Left:
Right:
3/5
3/5
2/5
2/5
1/5
1/5
Wrist flexion (Group VII)
0/5
5/5
4/5
4/5
0/5
5/5
Left:
Right:
3/5
3/5
2/5
2/5
1/5
1/5
0/5
5/5
4/5
4/5
0/5
5/5
Left:
Right:
3/5
3/5
2/5
2/5
1/5
1/5
Knee extension (Group XIV)
0/5
5/5
4/5
4/5
0/5
5/5
Left:
Right:
3/5
3/5
2/5
2/5
1/5
1/5
Left:
Right:
3/5
3/5
2/5
2/5
1/5
1/5
0/5
5/5
4/5
4/5
0/5
5/5
Left:
Right:
3/5
3/5
2/5
2/5
1/5
1/5
Provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk:
(Indicate side affected):
(Indicate muscle group(s) affected (I-XXIII) if possible):
Both
RightLeft
Frequency of use:ConstantOccasionalRegular
(If muscle atrophy is present, indicate location (such as calf, thigh, forearm, upper arm):
Other:
Frequency of use:ConstantOccasionalRegularWheelchair
Frequency of use:ConstantOccasionalRegularBrace(s)
Frequency of use:ConstantOccasionalRegularCrutch(es)
Frequency of use:ConstantOccasionalRegularCane(s)
Frequency of use:ConstantOccasionalRegularWalker
If muscle atrophy is present in more than one muscle group, provide location and measurements, using the same format:
cm. Atrophied side: Normal side:cm.
VA FORM 21-0960M-10, DEC 2014
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
15A. HAVE IMAGING STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
SECTION IX - DIAGNOSTIC TESTING
SECTION X - FUNCTIONAL IMPACT
Page 6
NOTE - If there is reason to believe there are retained metallic fragments in the muscle tissue, appropriate x-rays are required to determine location of retained metallic
fragment. Once retained metallic fragments have been documented, further imaging studies are usually not indicated.
(If "Yes," describe - brief summary)
YES
Location (specify muscle Group I -XXIII, if possible):
17. REMARKS
(If any)
18C. DATE SIGNED
18F. PHYSICIAN'S ADDRESS
18B. PHYSICIAN'S PRINTED NAME
(VA Regional Office FAX No.)
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
NOTE - A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
SECTION XII- PHYSICIAN'S CERTIFICATION AND SIGNATURE
IMPORTANT - Physician please fax the completed form to
18D. PHYSICIAN'S PHONE AND FAX NUMBER
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with
your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for
refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is
considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to
verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate
that you will need an average of 30 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid
OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB
Internet Page at www.reginfo.gov/public/do/PRAMain
. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
18A. PHYSICIAN'S SIGNATURE (Sign in ink)
13. DUE TO THE VETERAN'S MUSCLE CONDITIONS IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS
OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS?
(Functions of the upper extremity include grasping,
manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN
NO
SECTION VII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
(For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples - brief summary)
(If "Yes," indicate extremity(ies) for which this applies):
Right lower
15C. WERE ELECTRODIAGNOSTIC TESTS DONE?
Left lower
Right upper
Left upper
(If "Yes," indicate results):
YESNO
14. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
16. DOES THE VETERAN'S MUSCLE INJURY(IES) IMPACT HIS OR HER ABILITY TO WORK? (For example the muscle injury(ies) results in the veteran's inability to keep
up with work requirements)
YESNO
(If "Yes," was there diminished muscle excitability to pulsed electrical current?)
NO
YES
NO
X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile
(Indicate side affected):
BothRightLeft
15B. IS THERE X-RAY EVIDENCE OF RETAINED METALLIC FRAGMENTS (such as shell fragments or shrapnel) IN ANY MUSCLE GROUP?
(If "Yes," describe the impact of each of the veteran's muscle injuries, providing one or more examples):
YES
NO
Location (specify muscle Group I-XXIII, if possible):
X-ray evidence of retained shell fragment(s) and/or shrapnel
(Indicate side affected):
BothRightLeft
SECTION XI - REMARKS
YESNO
(If "Yes," name affected muscles)
15D. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YESNO
(If "Yes," provide type of test or procedure, date and results - brief summary)
VA FORM 21-0960M-10, DEC 2014
18E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
